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Indo
03-25-2010, 05:50 PM
OK. So over the past year or so I have been reading all kinds of things on this forum regarding healthcare and it has come to my attention that there is a large misperception/misconception made by people who are not in the healthcare profession about how things "work". I have been wanting for some time now to begin this thread. So here it is.

I will, from time to time, post some information about what I think is a common misperception among the general population (those that are not involved in providing healthcare). Having said that, this will be the first Lesson in Healthcare.



LESSON ONE



It is a common misconception that doctors and hospitals charge different fees to uninsured patients, Medicaid/Medicare patients, and private health insurance patients---that they bill one amount for a service to the patient and a different amount to the insurance provider and that they bill different amounts to uninsureds, 'Care/'caid patients and private insurance patients.



This is simply not true. In fact, it is illegal for any doctor or health care facility to have more than one Fee Schedule. This means that you must charge the same price for any given service to everyone. I will use a simple example:

Let's say that a doctor provides a service to a patient (a hernia operation, for example). What is not understood by many people is the concept of Reimbursement. Years ago the doctor would send a bill to his/her patient for the hernia operation. It would generally take a lonnnng time for the doctor to get paid because the patients had to contact their insurance company; the insurance co. would then send the money to the patient and the patient would turn around and send it to his doctor. Then the insurance companies (who were generally lead by Medicare) said, "Hey doctors! Tell you what---you'll love this! We will do you all a favor and help you get reimbursed for the service you provided (the hernia operation) by taking the inefficiency in the system out of the equation. Instead of you billing the patient and then they will have to contact us and then we will send the $$ to them and then they will send it to you (whew!), How about if you just send the bill directly to us, and then We will send the Reimbursement directly back to you! What a great Idea!" On paper and in theory it was...but what it really was was a way for insurance companies and Medicare/'caid to control the amount of the Reimbursements. Over time the Reimbusements have gotten smaller and smaller---I bet you didn't know that there is legislation currently pending that will decrease physician reimbursements by 21.5% (that's right TWENTY-ONE percent. How many of you could take a cut in pay by 21%? Me either. But that's a discussion for another thread...)

Back to the example.

So theway it works is that the doctor signs a contract with each and every insurance provider (including Medicare and Medicaid) to become a Provider of that type of insurance---meaning he can accept patients covered by that type of insurance. In technical jargon, he "Accepts Assignment", or agrees to accept whatever amount of money that that particular insurance company will pay for any given service. Is everyone following?

In our example, let's say that Frank Jones needs a hernia operation and he has Insurance XXX. Insurance XXX will pay $65 (I'm using low numbers to make it easy) and ONLY $65.

However, Insurance YYY will pay $80. Yes, different insurance companies pay different amounts within the same state and ACROSS states. Insurance YYY may pay $80 in Pennsylvania, but they will pay only $70 in South Dakota. (Do you begin to understand WHERE healthcare reform needs to change these types of things---not the crap they are handing us?)

Medicare may pay only $78
(To put things in real perspective, Medicare pays $651.92 for a hernia repair in Philadelphia but it pays only $583.85 in the rest of PA at the time of this post)

Does everyone see the problem here?
A doctor (or other health care facility can have ONLY one Fee Schedule (how much he bills for any given service provided). As a doctor you MUST bill the uninsured, the privately insured, and the Medicare/'caid patients THE SAME AMOUNT. It is ILLEGAL to bill different people different amounts.

Now, here is where it gets a little confusing:
Insurance XXX pays only $65
Insurance YYY pays $75
Insurance ZZZ may pay $90
Medicare (in this example) pays $78

What happens if the doctor sets his Fee for hernia repair at $65, but the patient has Insurance ZZZ? He gets paid $65, because THAT IS WHAT HE BILLED. Insurance ZZZ is willing to pay $90. But the doctor billed less, so he gets paid less.

What happens if the doctor sets his fee at $110. The patient has Insurance ZZZ and they will pay (reimburse) ONLY $90. The doctor gets paid $90.
Can the doctor then turn around and say, "Well, my fee is $110 and Ins. ZZZ paid me $90, so I will bill the patient the difference of $20".
NO. HE CANNOT. Remember, he signed a contract with Insurance ZZZ to "Accept Assignment". The Reimbursement Assigned to the service of Hernia Repair is $90. The doctor cannot, per the contract, turn around and bill the patient for the differnce.

In order for a doctor to collect as much payment as possible, he sets his Fee Schedule slightly above what the majority of insurance companies pay (in reality, it turns out to be about 150% of the Medicare Reimbursement Schedule).

So, for this example, the doctor sets his Fee Schedule for Hernia Repair at $85

Frank Jones has Insurance XXX----the doctor will get paid $65
Tom Smith has Ins. YYY---the doc will get paid $75
a patient with Ins. ZZZ ---the doc will get the full $85 (and, in fact, he could have gotten as much as $90, if his Fee Schedule was higher---but he Cannot change it. He must have a set Fee Schedule which is subject to audit).

Now, a patient who is uninsured will get a bill directly from the doc.---$85 in this case. We'll get back to that...another time.

So,looking at a patient with Insurance XXX---it appears as if the doctor billed the Ins. co. only $65 because the patient receives a paper that tells them that the doc was paid $65. But it may also say somewhere on the bill that the fee was $85. It gets confusing and appears that there were two different fees billed. There were not. The Fee was $85. The Insurance company agreed to pay $65. The doctor was obligated to accept the $65, or he would get NOTHING.

Insurance companies TELL doctors and hospitals how much they will pay. The doc/hosp. either accepts that much or gets nothing. Period.

HERE ENDETH THE LESSON

discuss

Godfather
03-25-2010, 08:50 PM
I bet you didn't know that there is legislation currently pending that will decrease physician reimbursements by 21.5% (that's right TWENTY-ONE percent. How many of you could take a cut in pay by 21%? Me either. But that's a discussion for another thread...)

You're greedy and get paid too much. You should have to spend 11 years becoming a doctor and deal with the constant stress of liability and med mal insurance jsut to get paid less than a postal worker like "good' countries would do.

ETA: You should get one of the doctors in Congress to introduce an amendment to that legislation that cuts Congressional pay by the same amount as doctor pay. It'll get voted down but anyone trying to cut doctor pay will embarrass themselves and expose themselves as hypocrites.

MACH1
03-25-2010, 10:26 PM
I bet you didn't know that there is legislation currently pending that will decrease physician reimbursements by 21.5% (that's right TWENTY-ONE percent. How many of you could take a cut in pay by 21%

That much I did know. Thats why it's getting harder and harder to find doc's that accept medicare/medicaid patients.

tony hipchest
03-25-2010, 10:53 PM
thanks indo for starting this thread. i went to college for pre-med with aspirations of being a sugeon and even took a few courses at UNM's medical college. the most compelling and thought provoking was Sociology of Medical Practice.

my final term paper was coping with stress and i was amazed how little research there was on how those with such intense, time consuming jobs dealt with or were taught to handle the stress of having ones life in their hands.

to put it in football terms, a surgeon either has 'it" or they dont.

point being i really respect your opinion on this topic and hope you can add a real life perspective to us on this board.

can you tell us how this is gonna affect you first hand (and i understand that, at this point, you may be as much in the dark as the rest of us)?

i keep hearing how everybody will no longer be "free to chose" which doctor they see.

when does the government ship you and all the other doctors out and bring in all the new doctors that will not be of the peoples choice?

when i was a kid applying for the ROTC to be a doctor (because i wanted to be a field medic saving the lives of soldiers), i was amazed to learn that military doctors were paid according to their rank, not according to their education or free market value.

are you going to get a rank? is our new socialist regime gonna eliminate "private practice"? will we eliminate all elective surgeries or will the elite such as nanci pelosi still be allowed to reconstruct herself to look like a 110 year old joan rivers?

i live in a town where the choice of doctors is about as varied as mcdonalds vs. burger king. sometimes the line for one is longer than the other. is that preparing me for the socialism i am about to endure or will it pretty much be more of the same ol same ol?

i know some of these questions are sorta tongue in cheek, but most of the concers we have heard on this board are from the patient/payers POV.

i am really interrested in the provider/earners point of view.

oh and another question... theoretically, if you were to catch an STD, are you legally able to diagnose and write yourself a precription to get rid of the itch w/o an outside consultation?

MasterOfPuppets
03-25-2010, 11:05 PM
bit off topic, but i remember reading before where a woman said the hospital included a fee for a circumsicion on the bill to her insurance company after she had a baby .... she gave birth to a girl......:toofunny:

Godfather
03-26-2010, 09:22 AM
i keep hearing how everybody will no longer be "free to chose" which doctor they see.

when does the government ship you and all the other doctors out and bring in all the new doctors that will not be of the peoples choice?

You'll lose your choice of doctor because you'll be FORCED to buy insurance and they tell you what doctor to see. And you won't be able to afford to go outside the system because you'll be paying out the wazoo for the premiums.

Indo
03-26-2010, 10:13 AM
thanks indo for starting this thread. i went to college for pre-med with aspirations of being a sugeon and even took a few courses at UNM's medical college. the most compelling and thought provoking was Sociology of Medical Practice.

my final term paper was coping with stress and i was amazed how little research there was on how those with such intense, time consuming jobs dealt with or were taught to handle the stress of having ones life in their hands.

to put it in football terms, a surgeon either has 'it" or they dont.

point being i really respect your opinion on this topic and hope you can add a real life perspective to us on this board.

can you tell us how this is gonna affect you first hand (and i understand that, at this point, you may be as much in the dark as the rest of us)?

i keep hearing how everybody will no longer be "free to chose" which doctor they see.

when does the government ship you and all the other doctors out and bring in all the new doctors that will not be of the peoples choice?

when i was a kid applying for the ROTC to be a doctor (because i wanted to be a field medic saving the lives of soldiers), i was amazed to learn that military doctors were paid according to their rank, not according to their education or free market value.

are you going to get a rank? is our new socialist regime gonna eliminate "private practice"? will we eliminate all elective surgeries or will the elite such as nanci pelosi still be allowed to reconstruct herself to look like a 110 year old joan rivers?

i live in a town where the choice of doctors is about as varied as mcdonalds vs. burger king. sometimes the line for one is longer than the other. is that preparing me for the socialism i am about to endure or will it pretty much be more of the same ol same ol?

i know some of these questions are sorta tongue in cheek, but most of the concers we have heard on this board are from the patient/payers POV.

i am really interrested in the provider/earners point of view.

oh and another question... theoretically, if you were to catch an STD, are you legally able to diagnose and write yourself a precription to get rid of the itch w/o an outside consultation?

Lots of good questions---unfortunately I am about to go operate on a patient with no insurance----you know, one of the ones who don't get good health care under the previously current system...
I'll respond to the questions as soon as I can...

steelax04
03-26-2010, 10:25 AM
You'll lose your choice of doctor because you'll be FORCED to buy insurance and they tell you what doctor to see. And you won't be able to afford to go outside the system because you'll be paying out the wazoo for the premiums.

Not all insurance tells you what doctor to go see. Even with HMOs you choose a PCP (Primary Care Physician) and that's the patient's choice. With a PPO, it's more open in the fact that you can choose to see whatever physician or specialist whenever you'd like. HMOs are more restrictive on that, but there are even 'open' HMOs that allow quite a bit of choice.

In-network and out-of-network is different than the insurance telling you what specific doctor you have to see.

Is this bill changing the way that insurance operates that the patient can't even choose their PCP anymore? If so, I'd like to see a link to that because that's a whole other can of worms that might not hold up to some Constitutional scrutiny.

lamberts-lost-tooth
03-28-2010, 12:09 PM
Lots of good questions---unfortunately I am about to go operate on a patient with no insurance----you know, one of the ones who don't get good health care under the previously current system...
I'll respond to the questions as soon as I can...

WHAT?????

That cant be true......

I saw Denzel Washington in the movie "John Q"!!!

I KNOW how the healthcare system operates dammit!!!!!!

chacha
03-28-2010, 03:48 PM
http://www.republican-elephant.com/cheney-5-heart-attacks.jpg

43Hitman
03-28-2010, 04:09 PM
So let me make sure I got this right Indo. First a little background on my situation. I recently was playing catch with my son and he managed to throw the football just right, I half missed it and it dislocated my finger. It was pretty bad, the front of my finger was actually under the back half, like this. Tip of finger____---------Knuckle at the hand. I hope that makes sense. So I know by looking at it that it's pretty messed up, cause it's pointing off to the right as well. It hurt like a bitch, so I decided the best thing to do was pull it back out(reset it?). At first it wouldn't go, but about 5 minutes later I was able to really pull on it and it popped back into place. Of course the swelling started a couple of minutes later. I took some Aleve and prayed it wasn't broken. Two days later I couldn't stand the pain anymore and decided to go the ER, doc wouldn't see me cause he had no X-Ray and it was Saturday. So I go the ER get an X-Ray a shot of lanacane(sp), get told it's not broken and get a script for a painkiller. Perkaset(sp) I think it was. I was in and out in 45min. Okay a month goes by and my insurance decides to use our FSA to pay for it. They sent us a check and we had to pay the doc. All is good except our FFA is drained now. 900$ bill. Now two months later I am getting bills from the Er and the orthopedic doc. It appears that these bill are the remainder of what the insurance didn't pay.

Okay since the background is somewhat laid out, here is my question. Based on what you're saying, am I not liable for the remainder of those bills because the doc already has agreed upon a certain price and that's what the insurance company paid?

43Hitman
03-28-2010, 04:11 PM
http://www.republican-elephant.com/cheney-5-heart-attacks.jpg

Why are you trying to derail this thread with mindless rhetoric? Seriously, there are other threads for that crap. KEEP IT THERE!

chacha
03-28-2010, 04:27 PM
It's a FREE world you damn Commie!! :toofunny:

43Hitman
03-28-2010, 05:22 PM
It's a FREE world you damn Commie!! :toofunny:

Typical.:coffee:

Indo
03-29-2010, 03:32 PM
OK, I'm back. Busy weekend...
I'll try to answer these question as best I can, but let me throw this disclaimer out there-----I'm just an average run-of-the-mill Steelers fan and not privileged enough to have had the opportunity to read the new healthcare legislation. With that being said, I will answer the questions as best I can, and post the info that is trickling out thru the med societies, etc., as I get it...




thanks indo for starting this thread. i went to college for pre-med with aspirations of being a sugeon and even took a few courses at UNM's medical college. the most compelling and thought provoking was Sociology of Medical Practice.
You, obviously, were intelligent enough to turn towards a different career!


my final term paper was coping with stress and i was amazed how little research there was on how those with such intense, time consuming jobs dealt with or were taught to handle the stress of having ones life in their hands.

We were not specifically taught how to cope with the stress but, being in New Orleans, we rapidly discovered the benefits of large quantities of Beer and other such beverages!


to put it in football terms, a surgeon either has 'it" or they dont.

point being i really respect your opinion on this topic and hope you can add a real life perspective to us on this board.

can you tell us how this is gonna affect you first hand (and i understand that, at this point, you may be as much in the dark as the rest of us)?

As I said, I haven't read the document----but I have a good idea what will happen...We will all begin to see healthcare rationing. Of course it won't be called "Rationing", but that is what it will be. As a physician, I will be told what tests I can order, which procedures will be approved, and what will be denied. This ALREADY happens to an extent. But that extent will be extended! It is already VERY difficult to get a CT scan or MRI approved for patients that have Medicaid (and the new "insurance" will be an off-shoot of Medicaid. For example: suppose Mr. Smith needs a CT scan of his abdomen. Approval for a CT scan is denied by Medicaid ALMOST 100% OF THE TIME now. And there is little recourse for the patient's MD to appeal the denial. Yes, we can write a letter explaining the situation, but it generally results in a second denial. Now, if I call a private insurance carrier (like BlueCross/BlueShield) there is a human-being who is generally a doctor (the medical director) of the insurance Co. who has a clue what I'm talking about. I can explain the situation and get approval (I can generally get 100% APPROVAL on tests that have been denied IF THERE IS A PERSON WITH A MEDICAL BACKGROUND TO TALK TO). When one calls the Medicaid office to get an approval you generally get to speak to someone who can't spell N-F-L----even if you spot them any two of the three letters!

So, it is my belief that this will become MUCH worse...it doesn't really affect me, but it greatly affects the patients if I can't order the proper tests, x-rays, etc.


i keep hearing how everybody will no longer be "free to chose" which doctor they see.

when does the government ship you and all the other doctors out and bring in all the new doctors that will not be of the peoples choice?

I'm not sure----what I can tell you is that about 2-3 years ago the govt. started keeping tabs on all of us as far as performance goes. For example, if the complication rate of a particular operation is, say 1%, but a particular doc has a complication rate which is outside the "average", say 8%, there is talk (don't know how accurate that "talk" is) that the doc with the high complication rate will no longer be able to perform that operation (he will still be "allowed" to perform it, he just won't get reimbursed for it----which affectively takes away his/her ability to perform it)

Scary, ain't it

when i was a kid applying for the ROTC to be a doctor (because i wanted to be a field medic saving the lives of soldiers), i was amazed to learn that military doctors were paid according to their rank, not according to their education or free market value.

Yes. I have posted something about this in another thread a while back (don't have time to find the post right now)----If one decides to opt for the military to pay for their medical education (they pay for 4 years of med school, then you owe them 4 years, sometimes 5 or 6, after you graduate). You graduate from med school and immediately are given the rank of Captain---and are paid according to your rank. I know a girl who finished med school as a Captain and then finished Surgery Residency and was promoted to Major. She then spent a year in Iraq running a MASH unit (like Colonel Blake or Potter). After 8 or so months in-theater the MASH unit was pulled back off of the front lines...she then came back to New Orleans and gave a lecture (complete with some really cool photos) of her experience



are you going to get a rank? is our new socialist regime gonna eliminate "private practice"? will we eliminate all elective surgeries or will the elite such as nanci pelosi still be allowed to reconstruct herself to look like a 110 year old joan rivers?

Hopefully Pelosi will ALWAYS be allowed to reconstruct herself, or we're all in serious trouble! I don't know if we will all get a rank, but I do think we will all be govt employees...


i live in a town where the choice of doctors is about as varied as mcdonalds vs. burger king. sometimes the line for one is longer than the other. is that preparing me for the socialism i am about to endure or will it pretty much be more of the same ol same ol?

Good question.
I think that what has been happening in Massachusetts is a good model for what will happen across the US----I remember reading that the average time to see a physician in Mass. increased from around 16-17 days to around 60 days because so many physicians left the area. I have a feeling that this is what will happen across the country. Look at Canada and England, for example. The waiting lists for procedures (heart bypasses and others are MONTHS long; I don't know the data specifically, but I would bet that a fairly large percentage of people die while waiting for their procedures)
i know some of these questions are sorta tongue in cheek, but most of the concers we have heard on this board are from the patient/payers POV.

i am really interrested in the provider/earners point of view.

oh and another question... theoretically, if you were to catch an STD, are you legally able to diagnose and write yourself a precription to get rid of the itch w/o an outside consultation?

:chuckle:
Yes, actually. I have baaaad allergies and I typically write my own prescriptions for the meds. But I WOULD NOT AND DO NOT write any prescriptions for myself or The Girl (same household) for any controlled drugs (like narcotics, sedatives,etc). That practice just raises all kinds of questions with the DEA


Here is something else that concerns me:

Think of an Insurance Company (any insurance co.----car, home, life, health) like a Casino. They are (in the case of Health Insurance) Gambling---putting up a Bet--- that you WON'T get sick. They charge you a fee (your premium) for them to make that bet. If they are correct (and, statistically they are for a high percentage of the bets they place), they win and get to keep the fee they charged you. For a small percentage, they are Wrong and you get sick and they have to pay out the bet at a loss. But if they place a high enough volume of bets, they will, in the long run, Win (make a profit).

So here is what concerns me-----insurance companies will now be forced, by the new legislation, to cover dependent "children" until they are 26 years old on their parents policy. Their will be many more bets placed without effectively increasing the fee for betting.The Insurance companies will be forced to cover many more people without increasing what is in their coffers to pay out when they lose. Now, I will grant you that the 18-26 year old age group typically does not have many sick people. But, when they do have a health issue it is usually a BIG and EXPENSIVE one because people in that age group are the most prone to motor vehicle accidents and other stupid behaviors which lead to accidents.
How does an insurance company continue to pay out claims to this age group (which typically has very expensive claims) without increasing the premiums to cover the losses? In my estimation, it doesn't. This will, IMO, contribute to the eventual replacement of all private insurance with govt insurance as the private coompanies are forced out of business---thereby completing the circle of completely Socialized Medicine.

chacha
03-29-2010, 03:38 PM
that was very interesting to read your point of view Indo! This is off topic but what do you think about the "boutique" medical practices popping up?

Indo
03-29-2010, 03:51 PM
So let me make sure I got this right Indo. First a little background on my situation. I recently was playing catch with my son and he managed to throw the football just right, I half missed it and it dislocated my finger. It was pretty bad, the front of my finger was actually under the back half, like this. Tip of finger____---------Knuckle at the hand. I hope that makes sense. So I know by looking at it that it's pretty messed up, cause it's pointing off to the right as well. It hurt like a bitch, so I decided the best thing to do was pull it back out(reset it?). At first it wouldn't go, but about 5 minutes later I was able to really pull on it and it popped back into place. Of course the swelling started a couple of minutes later. I took some Aleve and prayed it wasn't broken. Two days later I couldn't stand the pain anymore and decided to go the ER, doc wouldn't see me cause he had no X-Ray and it was Saturday. So I go the ER get an X-Ray a shot of lanacane(sp), get told it's not broken and get a script for a painkiller. Perkaset(sp) I think it was. I was in and out in 45min. Okay a month goes by and my insurance decides to use our FSA to pay for it. They sent us a check and we had to pay the doc. All is good except our FFA is drained now. 900$ bill. Now two months later I am getting bills from the Er and the orthopedic doc. It appears that these bill are the remainder of what the insurance didn't pay.

Okay since the background is somewhat laid out, here is my question. Based on what you're saying, am I not liable for the remainder of those bills because the doc already has agreed upon a certain price and that's what the insurance company paid?

The answer is----it depends.
Going to the ER is a whole different animal altogether.
You have to look at your specific policy and see what kind of co-pay you must pay to the hospital. An ER visit can cost $100, sometimes even up to $250 in co-pay. Think of it like a "deductible" over and above your yearly deductible.
Remember that ALL insurance policies (car, home, health, etc) have a deductible.
Generally, if you choose to pay a low(er) premium(monthly fee), you will have a higher deductible----again, it's a gamble. You're gambling that you WON'T get sick and therefore choose to pay a lower monthly premium at the risk of having to pay a Higher deductible if you do get sick.
On top of that, ALL healthcare policies have the "co-pay". Your policy may cover 80% of the bill and you owe 20%. Or it may cover 100%, but you still owe the co-pay...etc
Co-pay for a visit to the ER is typically high, as I said

So you need to look at your policy and see if your yearly deductible has previously been paid...if not, your ins. co. may be saying that you still need to pay because the deductible hasn't been met. Or, the hosp. is billing you the ER co-pay, for which you are responsible. A call to your insur. co. can usually clear it up.

Now, the payment to the Ortho. guy can be explained in the same way----he/she has billed for a service provided in the ER. First question, is he a provider of the type of insurance that you have? Has he signed a contract with them and agreed to "Accept Assignment" of what they will pay? Or is he "Out of Network" , as they say. In that case he is under no obligation to accept anything that they will pay and CAN bill you directly. If he is "In Network", he must accept what they will pay as he has signed a contract saying that he would. Again, your insur. co. can tell you.

Hope this makes sense...let me know if it doesn't

Indo
03-29-2010, 04:04 PM
that was very interesting to read your point of view Indo! This is off topic but what do you think about the "boutique" medical practices popping up?

Again, It Depends

Some of these facilities are run by very good doctors that have simply said, "I have had enough!" and they choose to stop accepting insurance altogether. Instead, they set up payment plans with their patients or they require that the service to be provided is paid in full prior to the procedure---

for example, I knew a guy in New Orleans who was a Plastic Surgeon who did only Cosmetic surgery and had his patients pay 10 days in advance for any procedure that he did. They wanted the procedures, so they paid. Sometimes as much as $25,000! Crazy, isn't it.

The problem occurs when someone less-than-ethical opens one of these "boutiques" because they are not really held to the same standards as hospitals, etc. The JCAHO (Joint Commision on the Accreditation of Healthcare Organizations) does not survey/inspect them and does not accredit them.

chacha
03-29-2010, 04:50 PM
thank you for your reply, much appreciated. I heard that some of the boutiques also charge a membership fee,

MACH1
03-29-2010, 06:07 PM
thank you for your reply, much appreciated. I heard that some of the boutiques also charge a membership fee,

Membership might be something like keeping a lawyer on retainer. Build up some bank in case you need it. :noidea:

tony hipchest
03-29-2010, 11:36 PM
OK, I'm back. Busy weekend...
I'll try to answer these question as best I can, but let me throw this disclaimer out there-----I'm just an average run-of-the-mill Steelers fan and not privileged enough to have had the opportunity to read the new healthcare legislation. With that being said, I will answer the questions as best I can, and post the info that is trickling out thru the med societies, etc., as I get it...

Here is something else that concerns me:

Think of an Insurance Company (any insurance co.----car, home, life, health) like a Casino. They are (in the case of Health Insurance) Gambling---putting up a Bet--- that you WON'T get sick. They charge you a fee (your premium) for them to make that bet. If they are correct (and, statistically they are for a high percentage of the bets they place), they win and get to keep the fee they charged you. For a small percentage, they are Wrong and you get sick and they have to pay out the bet at a loss. But if they place a high enough volume of bets, they will, in the long run, Win (make a profit).

So here is what concerns me-----insurance companies will now be forced, by the new legislation, to cover dependent "children" until they are 26 years old on their parents policy. Their will be many more bets placed without effectively increasing the fee for betting.The Insurance companies will be forced to cover many more people without increasing what is in their coffers to pay out when they lose. Now, I will grant you that the 18-26 year old age group typically does not have many sick people. But, when they do have a health issue it is usually a BIG and EXPENSIVE one because people in that age group are the most prone to motor vehicle accidents and other stupid behaviors which lead to accidents.
How does an insurance company continue to pay out claims to this age group (which typically has very expensive claims) without increasing the premiums to cover the losses? In my estimation, it doesn't. This will, IMO, contribute to the eventual replacement of all private insurance with govt insurance as the private coompanies are forced out of business---thereby completing the circle of completely Socialized Medicine.thanks indo. your post confirms alot of what i believe and have learned, and in the true spirit of this thread, this response should be educational to anyone who reads it. the candid and detailed response was kick ass!

personally i appreciate it cause i know your time is money, and this post was money. :thumbsup:

send the bill to-

1600 pennsylvania ave.
washington dc

"my man" will take care of it. :wink02: :chuckle:

:drink: heres to no stress!

43Hitman
03-30-2010, 09:11 AM
Thanks for your insight Indo. This is very good information and I appreciate it.

Indo
03-30-2010, 11:41 AM
Thanks for your insight Indo. This is very good information and I appreciate it.

Glad to help

How's you finger?

lamberts-lost-tooth
03-30-2010, 12:25 PM
Glad to help

How's you finger?

Dont answer that!!!!! You have NO idea if he is in your PPO!!!!!!
:rofl::rofl::rofl:

Indo
03-30-2010, 12:45 PM
Dont answer that!!!!! You have NO idea if he is in your PPO!!!!!!
:rofl::rofl::rofl:

:chuckle:

(DAMN! I'm just trying to drum up business wherever I can...)

43Hitman
03-30-2010, 01:03 PM
Glad to help

How's you finger?

Actually it's still a bit swollen and is very stiff most of the time. Kinda painful to bend it still. This happened in January too. I am not sure if this is normal, but I can't afford to go back to that specialist. It's too expensive right now.

Indo
03-31-2010, 12:48 PM
Actually it's still a bit swollen and is very stiff most of the time. Kinda painful to bend it still. This happened in January too. I am not sure if this is normal, but I can't afford to go back to that specialist. It's too expensive right now.

Ice, ice, and more ice will get the swelling down

And it needs to be immobilized. If you don't have one of those finger-splint thingies, try buddy-taping it to the next finger...

43Hitman
03-31-2010, 01:38 PM
Ice, ice, and more ice will get the swelling down

And it needs to be immobilized. If you don't have one of those finger-splint thingies, try buddy-taping it to the next finger...

Thanks man. If you're ever in town(Richmond, Va.), I'll buy ya a drink. Weather it be of the adult variety or otherwise. :thumbsup: :drink:

Indo
03-31-2010, 04:04 PM
Thanks man. If you're ever in town(Richmond, Va.), I'll buy ya a drink. Weather it be of the adult variety or otherwise. :thumbsup: :drink:

Oh, make no mistake, it WILL be of the adult variety...

(thanks for the invite---I don't specifically need the drink (but probably wouldn't turn it down!)...I'd just enjoy talkin' Steelers stuff...)

steelax04
03-31-2010, 04:36 PM
Thanks man. If you're ever in town(Richmond, Va.), I'll buy ya a drink. Weather it be of the adult variety or otherwise. :thumbsup: :drink:

Where do you hang out for Steelers games? I'm in the West End and found Glory Days to be pretty packed with Terrible Towels on most game days.

43Hitman
03-31-2010, 04:45 PM
If it's not on locally, which they usually are. I'll go to Sharky's or The Playing Field where there is usually a big contingent of Steeler fans. Where is Glory Days? I'll have to join you for a game.

Preacher
03-31-2010, 04:52 PM
OK. So over the past year or so I have been reading all kinds of things on this forum regarding healthcare and it has come to my attention that there is a large misperception/misconception made by people who are not in the healthcare profession about how things "work". I have been wanting for some time now to begin this thread. So here it is.

I will, from time to time, post some information about what I think is a common misperception among the general population (those that are not involved in providing healthcare). Having said that, this will be the first Lesson in Healthcare.



LESSON ONE



It is a common misconception that doctors and hospitals charge different fees to uninsured patients, Medicaid/Medicare patients, and private health insurance patients---that they bill one amount for a service to the patient and a different amount to the insurance provider and that they bill different amounts to uninsureds, 'Care/'caid patients and private insurance patients.



This is simply not true. In fact, it is illegal for any doctor or health care facility to have more than one Fee Schedule. This means that you must charge the same price for any given service to everyone. I will use a simple example:

Let's say that a doctor provides a service to a patient (a hernia operation, for example). What is not understood by many people is the concept of Reimbursement. Years ago the doctor would send a bill to his/her patient for the hernia operation. It would generally take a lonnnng time for the doctor to get paid because the patients had to contact their insurance company; the insurance co. would then send the money to the patient and the patient would turn around and send it to his doctor. Then the insurance companies (who were generally lead by Medicare) said, "Hey doctors! Tell you what---you'll love this! We will do you all a favor and help you get reimbursed for the service you provided (the hernia operation) by taking the inefficiency in the system out of the equation. Instead of you billing the patient and then they will have to contact us and then we will send the $$ to them and then they will send it to you (whew!), How about if you just send the bill directly to us, and then We will send the Reimbursement directly back to you! What a great Idea!" On paper and in theory it was...but what it really was was a way for insurance companies and Medicare/'caid to control the amount of the Reimbursements. Over time the Reimbusements have gotten smaller and smaller---I bet you didn't know that there is legislation currently pending that will decrease physician reimbursements by 21.5% (that's right TWENTY-ONE percent. How many of you could take a cut in pay by 21%? Me either. But that's a discussion for another thread...)

Back to the example.

So theway it works is that the doctor signs a contract with each and every insurance provider (including Medicare and Medicaid) to become a Provider of that type of insurance---meaning he can accept patients covered by that type of insurance. In technical jargon, he "Accepts Assignment", or agrees to accept whatever amount of money that that particular insurance company will pay for any given service. Is everyone following?

In our example, let's say that Frank Jones needs a hernia operation and he has Insurance XXX. Insurance XXX will pay $65 (I'm using low numbers to make it easy) and ONLY $65.

However, Insurance YYY will pay $80. Yes, different insurance companies pay different amounts within the same state and ACROSS states. Insurance YYY may pay $80 in Pennsylvania, but they will pay only $70 in South Dakota. (Do you begin to understand WHERE healthcare reform needs to change these types of things---not the crap they are handing us?)

Medicare may pay only $78
(To put things in real perspective, Medicare pays $651.92 for a hernia repair in Philadelphia but it pays only $583.85 in the rest of PA at the time of this post)

Does everyone see the problem here?
A doctor (or other health care facility can have ONLY one Fee Schedule (how much he bills for any given service provided). As a doctor you MUST bill the uninsured, the privately insured, and the Medicare/'caid patients THE SAME AMOUNT. It is ILLEGAL to bill different people different amounts.

Now, here is where it gets a little confusing:
Insurance XXX pays only $65
Insurance YYY pays $75
Insurance ZZZ may pay $90
Medicare (in this example) pays $78

What happens if the doctor sets his Fee for hernia repair at $65, but the patient has Insurance ZZZ? He gets paid $65, because THAT IS WHAT HE BILLED. Insurance ZZZ is willing to pay $90. But the doctor billed less, so he gets paid less.

What happens if the doctor sets his fee at $110. The patient has Insurance ZZZ and they will pay (reimburse) ONLY $90. The doctor gets paid $90.
Can the doctor then turn around and say, "Well, my fee is $110 and Ins. ZZZ paid me $90, so I will bill the patient the difference of $20".
NO. HE CANNOT. Remember, he signed a contract with Insurance ZZZ to "Accept Assignment". The Reimbursement Assigned to the service of Hernia Repair is $90. The doctor cannot, per the contract, turn around and bill the patient for the differnce.

In order for a doctor to collect as much payment as possible, he sets his Fee Schedule slightly above what the majority of insurance companies pay (in reality, it turns out to be about 150% of the Medicare Reimbursement Schedule).

So, for this example, the doctor sets his Fee Schedule for Hernia Repair at $85

Frank Jones has Insurance XXX----the doctor will get paid $65
Tom Smith has Ins. YYY---the doc will get paid $75
a patient with Ins. ZZZ ---the doc will get the full $85 (and, in fact, he could have gotten as much as $90, if his Fee Schedule was higher---but he Cannot change it. He must have a set Fee Schedule which is subject to audit).

Now, a patient who is uninsured will get a bill directly from the doc.---$85 in this case. We'll get back to that...another time.

So,looking at a patient with Insurance XXX---it appears as if the doctor billed the Ins. co. only $65 because the patient receives a paper that tells them that the doc was paid $65. But it may also say somewhere on the bill that the fee was $85. It gets confusing and appears that there were two different fees billed. There were not. The Fee was $85. The Insurance company agreed to pay $65. The doctor was obligated to accept the $65, or he would get NOTHING.

Insurance companies TELL doctors and hospitals how much they will pay. The doc/hosp. either accepts that much or gets nothing. Period.

HERE ENDETH THE LESSON

discuss

Indo... It is interesting hearing it from your perpective, as I spent some time working for Humana health care in the claims department (Please, take time now to vomit, wipe off your mouth, get a glass of water and then come back at the sound of Humana. I had to do the same when I just typed it... twice! LOL, but that again, is the substance of a different thread).

EDIT: Indo, I am a bit pedantic at times, explaining things like provider vs. facility, EOB, Superform, etc., but that is for others who read my post.. I have a feeling you already know that stuff :chuckle:

From the insurance perspective, it looked a little different.

1. The doctor in state A (call it Florida) and State B (call it Pennsylvania) has very different costs. For instance. In Florida (I'm making up this case from bits and pieces of a few other scenarios that really happened, it'll be somewhat far fetched to make the point). A OBGYN has to pay 1/2 a million dollars a year for malpractice. However, in PA, that same doctor only has would have to pay 200,000 a year. Thus, just to be in practice, the doctor in Florida has to pay out 300,000 a year more. Now, add to that air-conditioning, heating, electric, etc. etc., not to mention taxes (or lack of) and there comes out being a very different price for the two. Thus, for the insurance company to allow the doc in PA to be the charged the same amount as in Florida is giving away unnecessary money to the doc in PA. That would drive up Insurance costs across the board, as the Insur. companies would have to raise rates across the board to cover their new exposure.

2. From the insurance prospective, you are absolutely right about medicare allowable, contracted amount, and assignment. However, there are significant games that are also played. For instance. A doctor will agree to a contract with a company. Then, when they bill, they will list out 7 different ICD-9 codes which all fall under the general office visit. They (and more than likely, their office managers--who usually are trolls that come out from under a bridge for 8 hours a day) KNOW that the office procedure is contracted under a single code, but they do it anyways for 2 reasons. 1. They STILL attempt to get paid beyond contract and 2 (and more than likely the usual reason), because they THEN use the rejected amounts as leverage to demand better payment next time, stating that they have not received as much as they "thought" they should have.

3. The raising of the amounts to 150 percent over medicare allowable is usually a ruse by most doctors in a given area two drive up what the insurance company will pay. Then, when the insurance companies all start to increase the moneys, the doctors go to medicare and demand medicare allowable be raised, since they are having to accept payments that are 70,80, 90 percent below what they normally charge. Medicare allowable then changes. What happens next? doctors up their prices again to 150 % of medicare allowable in order to create the next wave of price increases.

4. Threatening the patients (This one is sometimes doctors, but more often than not it is hospitals. When it is doctors however, it is again usually the trolls known as office managers). Providers and facilities usually could care less about questions of payment. If they are not paid what THEY think THEY should be paid, one of the quickest and biggest threats is to send a nasty letter to the patient informing them that it will be turned over to collections, thus threatening their financial future (by hurting their credit record). This is done because the Greedy Trolls don't know how to read a contract nor do any kind of followup themselves.

Here is a common scenario. Mary goes to the hospital with a broken leg. While at the hospital, she sees the doctor, gets an X-ray, and then has a cast put on it. She then goes home. Mary now gets anywhere from 2-4 bills. One from the E.R. doctor, one from the facility (the hospital itself), and one from the specialist who had to set her leg (It was a particularly nasty fall). The specialist sent the bill on a Superform (hospital billing form). Because the facility has already billed and been paid, the Superform from the specialist has been rejected, the Greedy Troll back in the office, instead of working out herself, sends a bill directly to the patient. The patient calls the insurance company and rips the insurance company a new one. ME! on the other end of the line says, "Nope, they billed on the wrong form and it was rejected. They just have to submit it on a provider bill.

However, a month goes by, and no bill is submitted. Instead, the patient gets ANOTHER letter, this one threatening to turn the bill over to collections. Now the patient is Irate. Mary (patient) doesn't want her credit hurt, so she PAYS THE BILL! (Yes, it happens a whole lot). THEN, a billing specialist FINALLY gets around to billing the insurance company. The company pays, and the doctor double collects.

Because these payments that go out are 2000 to 50,000 dollars payments and include 10 to 300 cases at once, no one bothers going back and looking, and the doctors double collect... OR, the patient calls back when they get thier final EOB (explanation of benefits), and NOW are TICKED that the insurance company paid the doctor instead of reimbursing THE PATIENT.

________

I could go on and on, but from the insurance side, their are horrible things wrong with how the doctors do business. In the EXACT same way, from the doctors side, there are horrible things wrong with how insur. companies do business. And BOTH of them get screwed over by the govt.

I absolutely agree that healthcare needs to change. This system is broken. BUt I also think you would agree with me that it is broken more from govt. interference than from anything else (Except ignorant lawsuits).

steelax04
03-31-2010, 04:53 PM
If it's not on locally, which they usually are. I'll go to Sharky's or The Playing Field where there is usually a big contingent of Steeler fans. Where is Glory Days? I'll have to join you for a game.

Take Pump Road south, make a right on Ridgefield Parkway and its in the first shopping center. They have some killer cheese fries. I take in at least 3000 calories each game I go there. Lucky for me I was trying to stay in shape for the Monument Ave 10K and worked them off. One game they had to put the Steelers on the projection screen over the Redskins because there were so much B&G.


Ohsnap... sorry for the hijack... proceed as you were.

tony hipchest
03-31-2010, 04:58 PM
Actually it's still a bit swollen and is very stiff most of the time. Kinda painful to bend it still. .

i have the same problem with my wang.

This happened in January too. I am not sure if this is normal, but I can't afford to go back to that specialist. It's too expensive right now

my grandpa taught me a great home remedy-

"you need to soak it in cider".

if it works for my wang it cant be bad for your finger. :wink02:

43Hitman
03-31-2010, 05:13 PM
i have the same problem with my wang.



my grandpa taught me a great home remedy-

"you need to soak it in cider".

if it works for my wang it cant be bad for your finger. :wink02:

lol, I knew after I posted that, that someone would jump all over it.

steelax04
03-31-2010, 06:33 PM
i have the same problem with my wang.



my grandpa taught me a great home remedy-

"you need to soak it in cider".

if it works for my wang it cant be bad for your finger. :wink02:

Only Tony hijacks a thread by mentioning his wang... :chuckle: